U形外固定架结合有限内固定治疗干骺端粉碎性骨折

目的 介绍用U形外固定架治疗长骨干骺端经关节面的粉碎性骨折的疗效。方法 2000年2月～2002年9月对8例患者分别采用切开复位少量螺丝钉内固定及U形骨外固定架固定。结果 全部病例均得到随访,随访时间平均11个月。外固定架术后使用时间平均为3.5个月,骨折愈合时间平均为4.5个月,所有骨折均愈合。无骨不连等发生。终末随访时膝关节活动度平均屈95°,伸180°。踝关节平均背伸10°,跖屈28°。结论 外固定架结合有限内固定治疗经关节面的干骺端粉碎性骨折,可避免伤口并发症和骨不连的发生,即能维持骨折对位恢复关节面的解剖关系,又不妨碍关节活动,是治疗长骨干骺端经关节面粉碎性骨折的较好方法。     

Operative treatment of osteochondral nonunion of the distal humerus

Three patients with ununited osteochondral fracture fragments of the distal humerus (2 anterior capitellum and trochlea; 1 posterior trochlea) who had debridement and realignment of the nonunion, autogenous cancellous bone graft, and internal fixation an average of 6 (range, 5-8) months after injury were studied. The preoperative arc of elbow flexion was 80 degrees, 35 degrees, and 25 degrees. All 3 fractures healed without implant related complications or osteonecrosis. At 28, 27, and 46 months after the index procedure for nonunion, the patients had 95 degrees, 90 degrees, and 115 degrees arcs of elbow flexion. The scores on the Mayo Elbow Performance Index were 80, 80, and 95 (2 good, 1 excellent). Based on this limited experience, it seems that operative treatment of ununited osteochondral fracture fragments can achieve union without osteonecrosis. Attempts to improve the function of the native elbow rather than salvage the situation with interpositional or prosthetic arthroplasty are worthwhile.     

62例胫骨干骨折骨不连的形成原因及治疗

目的探讨胫骨干骨折后骨不连的发生原因和临床各种不同处理方法的治疗效果。方法对1998年1月至2007年1月期间我院收治的62例胫骨干骨折后骨不连病例临床资料进行回顾性分析。其中男50例,女12例;年龄平均37.4岁。AO 42-A型10例,42-B型9例,42-C型43例。开放性骨折34例,其中Gustilo型1例,型3例,A型12例,B型16例,C型2例,闭合性骨折28例。其中上1/3段5例,中1/3段14例,下1/3段43例。吸烟患者42例,非吸烟患者20例。根据骨不连类型将患者分为三组,其中肥大型骨不连组18例,萎缩型骨不连组31例,感染性骨不连组13例。采用交锁髓内钉固定34例,加压钢板内固定11例（其中1例为附加钢板固定）,外固定支架16例,单纯植骨1例。采用成组秩和检验比较患者骨折的愈合时间,美国骨科学会（american academy of orthopaedic surgeons,AAOS）下肢功能评分情况。结果本组患者骨不连的原因分别为局部血供差、机械性不稳定、骨折断端接触不良、感染、吸烟及全身因素等。61例患者达到骨折临床愈合,骨折愈合时间肥大型骨不连（5.2±1.5）个月,萎缩型骨不连（6.0±2.9）个月,感染性骨不连（9.8±3.8）个月,AAOS下肢功能评分肥大型骨不连（88.7±6.6）分,萎缩型骨不连（86.1±9.2）分,感染性骨不连（78.0±11.2）分。与肥大型、萎缩型骨不连相比,感染性骨不连骨折愈合时间长,功能结果差。结论胫骨干骨折后骨不连的原因很多,要尽量避免医源性因素导致骨不连发生的情况。在术前必须要明确每例骨不连患者的个体特异性,才能选择正确的手术治疗方式。感染性骨不连骨折愈合时间长,功能效果差,要在临床上尽量避免感染性骨不连的发生。     

Comparative study of the results of compound tibial shaft fractures treated by Ilizarov ring fixators and limb reconstruction system fixators

Purpose: Ilizarov ring fixator and limb reconstruction system (LRS) fixators have been used in the management of complex tibial fractures with severe soft tissue injuries, compound tibial fractures, and infected tibial nonunion for which conventional internal fixation cannot be contemplated. Fracture union and distraction osteogenesis can be done simultaneously with these external fixators, allowing early weight bearing. Several previous studies have shown almost equal results of rail and ring fixators for the compound tibial shaft fractures. Thus we performed a prospective study to evaluate the union rate, functional outcome and amount of limb lengthening after the treatment of compound tibial shaft fractures with or without infected nonunion by ring or LRS fixators. Methods: This prospective study was done at Sarojini Naidu Medical College and Hospital, Agra, India and included 32 patients of compound tibial shaft fractures with or without infected nonunion. There were 26 males and 6 females and the average age was 40 years. Patients were randomly divided into two groups (n=16 for each): one underwent Ilizarov fixation and the other received LRS fixation. Cases were followed up for 3e24 months, 6 months on average from September 2012 to October 2014. Functional and radiological outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria for both rail and ring fixators. Results: Union was achieved in all cases. Radiological outcome was found excellent in 68.75%, good in 18.75% and fair in 12.50% of cases treated by rail fixators whereas it was excellent in 56.25%, good in 18.75%, fair in 12.50% and poor in 12.50% of cases treated by ring fixators. Functional result was satisfactory in 75.00% of cases treated by rail fixator and 68.75% of cases treated by ring fixators whereas the corresponding rate of unsatisfactory was 25.00% vs. 31.25%. Conclusion: In our short-term assessment, LRS fixators show a better result than Ilizarov fixators in terms of fracture union and functional outcome with soft tissue care and limb length.     

Repair and reconstruction of severe leg injuries： retrospective review of eighty-five patients

Objective:To explore a good way of the reconstruction of severe tibial shaft fractures by using different flaps and external fixators. Methods: Eighty-five patients of TypeⅢC tibial shaft fractures with average age of 42.5 years were treated in our hospital from 1990 to 2005. Injuries were caused by motorcycle accidents in 66 patients, by machine accidents in 16 patients, and by stone bruise in 3 patients. The management procedures consisted of administration of antibiotics, serial debridment, bone grafting if needed, application of different flaps, such as free thoracoumbilical flaps, fasciocutaneous flaps, saphenous neurocutaneous vascular flaps, sural neurocutaneous vascular flaps and gastrocnemius muscular flaps, and different external fixations, for instance, half-ring fixators, unilateral axial dynamic fixators, AO fixators, Weifang fixators, and Hybrid fixators. The average follow up was 6.3 years. Results: All flaps survived. Eighty-three cases had bone healed. The average bone healing time of different external fixations was 5.5 months in 47 cases with half-ring fixators, 9.2 months in 4 cases treated with unilateral axial dynamic fixators, 8.5 months in 6 cases with AO fixators, 10.7 months in 16 cases with Weifang fixators, and 7.8 months in 10 cases with assembly fixators. Except half-ring fixation, other fixations all needed necessary bone graft. Two cases treated with unilateral axial dynamic fixators had nonunion of bone and developed osteomyelitis. The wounds healed after the removal of the fixators and immobilization by plaster. The last follow up examination showed ankle and knee motion was normal and no pain was noted. Conclusions: The combination of half-ring external fixators with various flaps provides good results for TypeⅢC tibial shaft fractures.     

Treatment of nonunion of fractures in the epiphyseal-metaphyseal region of long bones

Twenty-four consecutive patients with fracture nonunion in the metaphyseal-epiphyseal areas of long bones were surgically treated. Average time from injury to treatment of the nonunion was 10 months, and average follow-up time after surgical treatment was 29 months. Eight patients with infected nonunions had initial debridement procedures; three of these patients then had placement of external fixators and bone grafting. The remaining five patients and 13 others were then treated by open reduction and internal fixation alone or with the addition of autogenous cancellous bone grafting. Single or double plates and screws were used. Arthrolysis, joint manipulation, and intensive postsurgical exercises were considered necessary to regain joint function. One patient underwent a hemiarthroplasty, and two others underwent arthrodesis as the initial nonunion treatment. Twenty of the 21 patients not treated by arthrodesis or arthroplasty healed their fractures in an average time of 7 months. Fifty-two percent of the patients achieved good or excellent range of motion (ROM) of the contiguous joint, with 70% of the patients reporting no pain in this joint. These fractures have excellent intrinsic healing capability because they occur in anatomical regions with a normally abundant circulation. We recommend stable fixation, with the need for bone grafting only in defect nonunions, together with intra- and postoperative joint mobilization to obtain a satisfactory functional end result.     

手术治疗四肢骨折后骨不连263例

目的回顾性分析四肢骨折后骨不连的发生原因及手术治疗结果。方法1996年5月～2005年8月共收治263例四肢骨折后骨不连患者。骨不连部位：股骨近端13例,股骨干57例,胫骨81例,肱骨51例,尺桡骨44例,锁骨5例,髋臼2例,舟骨3例,距骨4例,其它3例。本组患者全部采用手术治疗,其中交锁髓内钉固定157例,钢板螺钉固定72例,外固定架固定34例。植骨方法：单纯自体松质骨移植189例,自体松质骨混合其它材料移植57例,带血管蒂的游离骨瓣移植10例,自体骨髓移植4例,骨加压延长术3例。结果本组患者发生骨不连的主要原因为应力干扰和局部血供差,其次为感染、骨缺损及骨折复位不良、对位差、骨折间隙过大。242例患者获平均14．3个月(4～48个月)随访。242例患者均获骨性愈合,骨折愈合时间平均为5．3个月(3～18个月)。其中220例患者(90．9%)肢体功能优,无跛行等后遗症；22例患者(9．1%)遗留邻近关节活动受限、肢体短缩及跛行等许发症。结论骨不连的发生原因是多方面的,如果在治疗骨折时足够重视,多数骨不连可以避免。骨不连采用手术重新固定加自体植骨可获得良好疗效。     

Surgical management of delayed union and nonunion of distal radius fractures

Ten patients with malaligned fractures of the distal radius that demonstrated either delayed healing or the development of an atrophic or synovial nonunion on standard radiographs were treated with surgical realignment, stable internal fixation, and autogenous iliac crest bone grafting. All 10 fractures healed with acceptable radiologic alignment within 3 months of the index procedure. After an average follow-up period of 3 years 6 months (range, 2 years to 8 years 6 months) patients had an average of 105 degrees wrist flexion and extension, 145 degrees forearm rotation, and 73% grip strength compared with the opposite limb. In the treatment of malaligned, ununited fractures of the distal radius, specific techniques and implants must be tailored to the deformity of the distal radius and the shape of the distal fragment. A stable, well-aligned wrist with preservation of at least 50 degrees mobility in flexion and extension was achieved in every patient, but the final result was compromised by associated problems in 3 patients.     

Mennen plate fixation for the treatment of periprosthetic femoral fractures: a multicenter study of thirty-six fractures

BACKGROUND: The management of periprosthetic femoral fractures after total hip and knee replacement remains difficult and controversial. This study was performed to determine the results of Mennen plate fixation for the treatment of periprosthetic femoral fractures. METHODS: This retrospective multicenter study consists of a review of a consecutive series of thirty-five patients in whom a total of thirty-six periprosthetic femoral fractures were treated with Mennen plate fixation. The average duration of follow-up was twenty-seven months (range, eight to forty-six months). RESULTS: Twenty-six fractures (72%) had united at an average of five months (range, three to ten months) after surgery. One of them had varus bending (10 degrees) of the plate. The remaining ten fractures had a nonunion and varus bending (20 degrees to 30 degrees) of the plate, with a fracture of the plate in eight. A revision procedure was successfully performed in the eight patients with nonunion. CONCLUSIONS: The treatment of unstable periprosthetic femoral fractures with Mennen plate fixation was complicated by high rates of mechanical failure (31%) and nonunion (28%). For this reason, we do not recommend the use of the Mennen plate for the treatment of periprosthetic femoral fractures.     

Coronal fractures of the femoral condyle: a brief report of five cases

Coronal fractures of the femoral condyle (Hoffa fractures) are uncommon injuries that have a better outcome when treated surgically. We report a series of five Hoffa fractures (including one nonunion) treated at a Level 1 trauma center by one surgeon employing a protocol of open reduction and internal fixation with lag screws through a formal parapatellar approach. Postoperatively, all patients began immediate unrestricted range of motion. Initial weight bearing was limited, but all patients were permitted full weight bearing by 10 weeks. All fractures healed within 12 weeks without complications. The final range of motion for the patients with acute fractures was at least 0 degrees to 115 degrees. The patient with a nonunion had a preoperative flexion contracture of 20 degrees and a final range of motion of 20 degrees to 125 degrees. Long-term follow-up (average 37 months, range 18-57 months) was available for 3 of the 5 patients, and Knee Society scores were calculated for these patients (average 173 of 200 points, range 160-180 points). The literature regarding the management of Hoffa fractures is reviewed.     

抗感染重组合异种骨植入治疗四肢骨折内固定术后骨不连

目的探讨抗感染重组合异种骨(ARBX)植骨治疗四肢骨折内固定术后骨不连的临床疗效。方法取除原内固定、重新内固定或外固定,并应用抗感染重组合异种骨植入治疗四肢骨折内固定术后骨不连20例,全部为无菌性骨不连。断端应用ARBX植骨20例,混合自体髂骨移植9例。结果20例随访1年2个月～4年2个月,平均2年8个月。20例应用ARBX植骨治疗的骨不连中,18例完全愈合,1例延迟愈合,1例未愈合。无1例骨感染发生。结论重新内固定或外固定,避免了原手术方式存在的引起骨不连的内在因素;ARBX植骨治疗骨不连安全,对促进骨愈合疗效可靠。     

L-dopa in the treatment of nonunited fractures

Twenty-five patients with delayed or nonunion of fractures of a long bone had adjunctive treatment with levodopa (L-dopa). Presumably, L-dopa stimulates growth hormone, which has been suggested as helpful in bone growth and repair. All patients had previously been immobilized, and 22 had one or more surgical procedures. L-dopa was administered 500 mg initially and over three weeks was gradually increased to 500 mg orally three times a day. Treatment was continued for six months or until the fracture healed. After six months, 21 patients (84%) had no pain with full activity and solid bony union by roentgenograms and were considered healed. This study suggests that L-dopa improves the capacity of nonunited fractures to heal. Proof would require a randomized, double-blind series of patients. L-dopa could prove to be a useful adjunct in the management of delayed or nonunion of long-bone fractures.     

Chronic sepsis following intramedullary nailing of femoral fractures

We reviewed 12 patients with chronic drainage after intramedullary nailing of a femoral shaft fracture. The fractures tended to be the result of high-speed trauma and were frequently comminuted. Six were open fractures and six were closed injuries. All but one had been managed initially with the open nailing technique, exposing the fracture site. In six cases we left the nail in place until bone union occurred, an average of 33 months after injury, removing the hardware thereafter. The remaining six patients, each with bone sequestra at the fracture site, underwent nail removal, debridement of nonviable bone, and external fixation followed by bone grafting; this group took 37 months to heal. There was one persistent nonunion in each group. Drainage did not cease in either group until the nail and all sequestra had been removed. There was an average of 4.3 cm of shortening, but no angulation greater than 10 degrees. Six patients were left with less than 45 degrees of knee flexion and only five had 100 degrees or more of knee flexion.     

Nonoperative treatment of ipsilateral fractures of the scapula and clavicle

BACKGROUND: Internal fixation of one or both bones is the recommended treatment for floating shoulder injuries (ipsilateral fractures of the scapula and clavicle). Perceived risks of nonoperative treatment include abduction weakness, decreased range of motion, chronic pain, malunion, and nonunion. None of these problems, however, have been confirmed by clinical studies. The purpose of this retrospective study was to analyze the clinical and radiographic results of nonoperative treatment of floating shoulder injuries. METHODS: Twenty patients with a floating shoulder injury were treated with either a sling or a shoulder immobilizer. Eleven clavicular fractures were displaced ten millimeters or more, and five scapular fractures were displaced more than five millimeters. Physical therapy was begun three days to two weeks after the injury. Patients were evaluated with three separate scoring systems: those of Herscovici et al., Rowe, and Constant and Murley. Shoulder abduction and flexion were measured, and abduction strength was evaluated by clinical examination and comparison with the uninjured extremity. The duration of follow-up averaged twenty-eight months (range, nine to seventy-nine months). RESULTS: Nineteen of the twenty pairs of fractures united uneventfully. One clavicular nonunion occurred secondary to segmental bone loss from a gunshot wound. On the basis of the Herscovici rating system, seventeen patients had an excellent result and three had a good result. According to the Rowe system, eighteen patients had an excellent result, one had a good result, and one had a fair result. The average Rowe score was 95. The average Constant score was 96. In all twenty patients, the strength of the injured extremity was equal to that of the uninjured extremity. Eighteen patients had a full, symmetrical range of shoulder motion, one lost 15 degrees of flexion, and one lost 20 degrees of abduction. CONCLUSIONS: Nonoperative treatment of floating shoulder injuries, especially those with less than five millimeters of fracture displacement, can achieve satisfactory results that are probably equal or superior to those reported after operative treatment, without the risk of operative complications.     

Judet's quadricepsplasty, surgical technique, and results in limb reconstruction

Quadricepsplasty has been described by Thompson and Judet to improve flexion in severely ankylosed knees. Judet's technique has potential advantages because it is less damaging to the quadriceps mechanism and addresses the problem of external fixator pin site tethering on the lateral side of the thigh. The outcome of Judet's quadricepsplasty was assessed in 10 consecutive patients who were treated with external fixation either as a primary treatment (three patients) or as a secondary treatment for nonunion or malunion (seven patients) in a limb reconstruction unit. The patients were reviewed and examined at a minimal followup of 20 months. Their average prequadricepsplasty flexion of 33 degrees was improved to 105 degrees in the operating room and to 88 degrees on final review after an average followup of 24 months. According to Judet's criteria, there were one fair, seven good, and two excellent results. Two patients had postoperative complications, one hematoma and one infection. A minimal extension lag (10 degrees ) developed in one patient. Judet quadricepsplasty successfully increases flexion range with minimum impairment of quadriceps function. Familiarity with this technique might lower the surgeon's threshold for considering quadricepsplasty in patients with severe knee ankylosis after severe femoral fractures and in particular after a prolonged period of external fixation.     

Clavicular nonunions treated with compression plate fixation and cancellous bone grafting: the functional outcome.

We evaluated fracture healing and functional outcome after surgery in 16 patients with midshaft clavicular nonunion. The operative treatment consisted of compression plate fixation and autologous cancellous bone graft. The follow-up examination took place at an average of 54 months (range 26 to 90 months) after surgery. Radiographs were reviewed, and 12 patients underwent clinical review. All fractures united successfully. Two patients had a second operation because of loosening of the screws shortly after the first operation. Eleven of 12 patients had a good or excellent Constant score (>70 points). Nine of 12 patients returned to their preinjury activity level. Treatment with compression plate and autologous cancellous bone graft yields a high rate of healing and an acceptable functional outcome.     

Endoscopically assisted allogeneic bone grafting for atrophic nonunion of femur and tibia

BackgroundThe nonunion rate for all fractures is about 5–10%. The treatment of nonunion is based on the biologic and mechanical factors contributing to the cause of the nonunion. Debridement and bone grafting are the standard procedures used to treat nonunion of fractures.PurposeWe evaluated the results of endoscopically assisted allogeneic bone grafting performed to treat the nonunion of tibial and femoral fractures.MethodsBetween May 2006 and January 2011, eight patients (two men and six women) with tibial or femoral fracture nonunion were enrolled into our study. The average age of the patients was 35.4 years (range, 24–56 years). All patients underwent endoscopically assisted allogeneic bone graft implantation. We recorded the union status, clinical symptoms, and complications in all patients.ResultsThe average time from the fracture to surgery was 14.4 months (range, 9–22 months). The average follow-up period was 19.1 months (range, 9–28 months). Seven patients achieved bone union and only one patient required additional surgery. The average time between surgery and bone union was 6.4 months (range, 4–8 months). No major complications were reported.ConclusionEndoscopically assisted allogeneic bone grafting is a less invasive and effective treatment for atrophic nonunion of fractures.     

Surgical fixation of intra-articular fractures of the distal humerus in adults

We reviewed 15 adult patients with intra-articular fractures of the distal humerus treated over a period of 2 years. All patients underwent primary open reduction and internal fixation, which included 11 double plating procedures. The fractures were classified according to the AO/ASIF system. Patient outcome was assessed subjectively by scoring the patients' residual symptom of pain and their overall satisfaction of the treatment received. Objective assessment was performed using the Mayo Elbow Performance Index (range of motion, assessment of functional status, pain and stability of the joint). At a mean follow-up of 12.3 months, 7 patients were rated as excellent; 6, as good; one, as fair; and one, as poor. These cases had an average arc of flexion of 109.7 degrees. The sub-group of type C fractures without revision surgery had a mean flexion arc of 110.7 degrees (95-140 degrees ), with 100% Good to Excellent scores. Complications included two post-operative ulnar nerve neuropraxia, one wound infection, and one fracture fibrous non-union. Three patients required revision surgery which included a total elbow arthroplasty for implant failure, whilst four patients (including the patient with the subsequent arthroplasty) required joint mobilisation procedures for residual stiffness.     

Diaphysäre Femurpseudarthrosen – nur ein technisches Problem?

Between 1981 and 1994 at the Bergmannsheil Ruhr University Hospital in Bochum, Germany, we treated 145 patients with femoral diaphyseal nonunions following initial operative treatment. Of these patients, 138 received this initial operative treatment at an outside institution. The primary reconstructions for the fractures utilized plates in 112 cases, reamed nails in 24 cases and external fixators in 9 cases. The average age of the patients was 35 years and the mean time from the initial operative treatment was 2 years. Twenty-seven patients (19%) presented with a hypertrophic nonunion and 118 (81%) with an atrophic nonunion. There was a significant correlation between primary "classic" plating and development of an atrophic nonunion (chi 2-test: P < 0.01). We observed 34 wound infections (23%) with no significant correlation to the type of primary osteosynthesis. We determined that 73 of the pseudarthroses were due to improper osteosynthesis techniques. Of these cases, 41% involved the use of plates, 83% involved the use of reamed nails, and 78% involved the use of external fixators. Fracture location near the diaphyseal-metaphyseal junctions was common in this problematic group. Ninety-two percent of all plates led to atrophic nonunions. There were 21 open fractures and of these 90% (n = 19) developed an atrophic pseudarthrosis and 29% (n = 6) developed a wound infection. Fifty-seven (39%) of all patients had additional injuries, but we found that did not increase the risk of disturbed bone healing. Our revision operations focused on the elimination of wound infections, refreshment of bone healing, and improvement in fragment stability. Only 28% of all "classic" plates and 11% of all external fixators were changed to an intramedullary implant at the time of the first revision surgery. Hypertrophic nonunions required a mean of 1.3 revision operations to achieve bone healing whereas a mean of 2 revision operations were necessary to fuse atrophic bone ends (P < 0.05). In cases of diaphyseal pseudarthrosis healing time was not affected by the type of osteosynthesis used for primary reconstructions. Since lack of fracture healing can often already be observed directly from postoperative X-rays, we recommend that revision procedures be performed early. The prolonged length of time to care for femoral nonunions underlines the importance of appropriate primary fracture treatment. That takes into consideration both the biomechanical and the biological aspects of bone healing.     

微创撬拨复位植骨加外固定治疗桡骨远端不稳定骨折

目的 采用外固定架加撬拨复位植骨治疗桡骨远端不稳定骨折,并对其临床疗效进行初步评价. 方法 2005年9月-2007年5月,应用撬拨复位植骨加外固定治疗桡骨远端不稳定骨折27例.男16例,女11例;年龄18～69岁,平均49.3岁.跌伤19例,坠落伤1例,交通伤6例,钝器打击伤1例.均为闭合新鲜骨折.骨折按AO分型C1型13例,C2型11例,C3型3例.术前掌倾角-38～10°,平均-12.2°;尺偏角6～30°,平均19.1°.伤后至手术时间1～3 d.术后评估腕关节功能及骨愈合状况. 结果 27例术后获随访4～24个月,平均13.1个月.均无钉道骨折或感染、支架移位、血管及桡神经损伤等并发症发生.按改良Mcbride评分,优10例,良13例,可3例,差1例,优良率85.2%.并发创伤性关节炎1例,腕关节僵硬1例.术后掌倾角0～20°,平均13.4°;尺偏角10～33°,平均22.1°.术后8～10周骨折愈合,平均9.3周. 结论 撬拨复位植骨加外固定治疗桡骨远端不稳定骨折具有操作简便、复位满意的优点,有利于恢复腕关节正常解剖结构,降低创伤性关节炎的发生率.